Externalizing an ‘Asset Model’ of Activation: Creative Institutional Work by Frontline Workers in the Norwegian Labour and Welfare Service

The past two decades have brought significant shifts in Norwegian activation policy towards a joined‐up and employability‐enhancing approach to labour market inclusion in order to promote return‐to‐work despite health problems or disabilities. Utilizing a concept from health promotion, we term this approach an ‘asset model’ of activation. The Norwegian Labour and Welfare Service (NAV) and its local offices are the main agents implementing the new policy. This article aims to investigate the strategies that the frontline workers of NAV engage in, in order to externalize an ‘asset model’ in the adjacent medical field and to the general practitioners (GPs) in particular. We analyze these strategies as forms of creative institutional work – the purposive actions undertaken to change existing presumptions and opinions among relevant actors. We argue that although the new activation policy is not theirs to develop, in order to bring about changes in practice, ‘creating’ institutional work by the frontline workers is required. Our findings show that the frontline workers develop strategies in order to externalize an asset model to the GPs, as part of operationalizing an ‘activation’ reform into practice. We identify four forms of ‘creating’ institutional work undertaken by the frontline workers: ‘defining’ – enacting legislation and regulation in relation to GPs; ‘constructing normative networks’ – creating a more collaborative relationship with the GPs; ‘educating’ – teaching the GPs about the rules and regulations, and the opportunities and assistive measures they can offer to the injured; and thereby also ‘changing normative associations’ of GPs towards the activation policy.     

Beyond Rhetorical Differences: A Cohesive Account of Post‐devolution Developments in UK Health Policy

Health is perhaps the most significant policy area to be devolved to decision‐makers in Northern Ireland, Scotland and Wales. Consequently, there has been a great deal of interest in assessing the extent to which health policies (which already differed somewhat prior to devolution) have diverged since 1999. To date, analyses have tended to focus either on health care policies or on specific public health issues (e.g. health inequalities or tobacco control). The story that emerges from this body of work suggests health care policies have diverged significantly, whilst public health policies have remained remarkably similar. This article is one of the first to consider health care and public health policy alongside each other. It reassesses and updates previous analyses, incorporating developments relating to the 2010 general election and the 2007 and 2011 devolved administration elections. Drawing on a variety of textual sources (policy documents, research evidence and corporate literature), our findings differ from existing analyses in suggesting that, despite some noticeable differences in policy rhetoric, approaches to both health care provision and tackling public health problems remain similar. Looking to the future, the article concludes that the common economic challenges, combined with a tight fiscal policy (that remains excepted from devolution), means the similarities in health care provision across the UK are likely to remain more pronounced than the differences. However, current debate about the constitutional settlement, and in particular the prospect of greater fiscal freedoms for the devolved administrations, may provide opportunities for more meaningful divergence in health policy than has been possible hitherto.     

‘Problematising’ Australian policy representations in responses to the physical health of people with mental health disorders

Australia, like other jurisdictions, is recognising the poorer physical health of people with mental health disorders. This paper explores policy responses to this issue through discourse analysis of 22 Australian Federal and State government policy documents published in 2006–2011. The paper utilises Bacchi's ‘what's the problem represented to be?‘ approach to explore policy solutions in relation to the representation of the issue, enabling identification of issues which are not problematised and policy solutions that have not been considered. The poor physical health of people with mental health disorders is attributed in policy to poor lifestyle habits and limited access to monitoring of physical health care. Three policy solutions are offered: collaborative care delivery involving greater use of fee‐for‐service primary care to manage physical health; the monitoring of physical health status by mental health teams; and the promotion of lifestyle change. These solutions fail to address ongoing issues with collaboration between specialist mental health and primary care services. Reliance upon fee‐for‐service primary mental health care may, in fact, reduce rather than increase access to services. The strategies are discussed in light of neoliberal ideals of governance and personhood which are underpinned by informed consumer choice and personal responsibility for health.     

“Respect for each gender”: Gender,equity and backlash in Australia's male health policy

Australia is one of the few countries which has specific health policies for boys/men and girls/women as distinct groups. In this article I present an analysis of the discourses of gender, equity and disadvantage drawn upon in Australia's men's health policy. Through comparison with the women's health policy, I show that a dual focus on the essential differences between men and women and the ways in which the health system has failed men contribute to an adversarial gender politics, positioning men and women as rivals with competing needs. Reflecting broader debates concerning the negative impact of societal change on boys/men, I argue that, in its current form, Australia's health policy both taps into and, crucially, legitimises backlash politics, enabling it to ‘pass’ as sound public policy.     

Attributing Outcomes to Social Policy Interventions – ‘Gold Standard’ or ‘Fool's Gold’ in Public Policy and Management?

In recent years there has been increased interest in outcome‐based social policy‐making and management. The UK has been in the forefront of this movement but similar movements have been identified internationally. This interest in outcome‐based decision‐making has been given particular impetus through the ‘results’‐based movement in evaluation and performance management since the 1980s, which has increased in scope over time, slowly changing its emphasis from cost reduction and measuring outputs to measuring outcomes. This change has been widely welcomed by policymakers, practitioners and academics. However, there is evidence that the reality is often rather less than the rhetoric. Moreover, the ‘attribution problem’ of attributing changes in outcomes to specific social policies has remained a major issue. The conceptual solution of constructing ‘cause‐and‐effect’ models, imported from the policy evaluation field, has only recently become common for operationalising these models. This article outlines the evolution of interest in outcome‐based social policy‐making up to recent times and the growing realization of the importance of the attribution problem. It then outlines both how the ‘cause‐and‐effect’ policy modelling approach can partially tackle the attribution problem, but also its inherent limitations. Lastly, the article uses several case studies in current UK social policy‐making to demonstrate the potential importance of the reasoning embedded within cause‐and‐effect models but also the dangers in policy‐making which adopts this approach without understanding its conceptual basis or in fields where it is inappropriate, given the current state of our knowledge of social policy systems.     

Public Policy and Inequalities of Choice and Autonomy

Choice by service users has been promoted in social policy across many developed welfare states, often on the grounds that it will incentivize providers to enhance quality and efficiency. But this instrumental motivation for the promotion of choice overlooks the possibility that choice, understood in the deeper sense of autonomy, has intrinsic value, as suggested by egalitarian and capability‐based theories of social justice. This article argues that the narrow motivation of choice policies leads to a focus on services rather than outcomes for individuals and fails to address deep‐seated inequalities in the opportunities people have for real autonomy. We test this concept using newly collected data for the UK. Our empirical findings indicate that disabled people are more likely to experience constrained autonomy in all respects, while being from a low socio‐economic group and/or lacking educational qualifications is a risk factor across several components. We conclude that improving the ‘choice’ agenda for policy requires: (1) adopting a more sophisticated concept of ‘choice’ such as the conceptualization of ‘choice as autonomy’ outlined here; (2) developing a better understanding of existing inequalities in autonomy, such as we begin to explore in our empirical results; and (3) tackling these inequalities through, for example, the removal of obstacles to active decision‐making by providing effective support and advocacy, especially for disabled people, and addressing the major structural barriers – poverty, ill health and geographical inequality – which place significant restrictions on the autonomy of those who are already disadvantaged.     

Identifying health inequalities between Māori and non‐Māori using mortality tables

Abstract

While there is a need for more detailed information on health inequality to guide public health policy, the most complete and easily available data remain those in mortality tables. We investigate, via a comparative analysis of data from New Zealand on Māori and non‐Māori mortality, whether more detailed information than raw life expectancy may be extracted from the mortality tables. Given a parametric distribution for the mortality capable of fitting irregularities in mortality table data, the curvature of the survival and hazard rates can identify changes in mortality rates, such as infant and late‐life adult mortality, which allows for straightforward comparisons between the two sub‐populations. Our results identify an exogenous effect in earlier mortality among Maori, which correlates well with many published observations of health and health‐care inequalities between Māori and non‐Māori. This “proof of concept” for our method of analysis indicates that examination of bulk data such as those in mortality tables has a potential role in the design of more detailed studies involving causes of mortality.     

From State Security Model to Selective + Residual Security Model: Health care regime shift in urban China

Based on the study of welfare states, welfare regime theory (WRT) has been widely applied to international and regional welfare regimes and to specific‐policy comparative studies. However, the health care system has often been neglected in this area of study. The current study promotes a health care regime approach that is influenced by WRT and incorporates analysis of the level of health care de‐commodification and health equity. Three types of health care regimes were identified in the development of the health care system in urban China: the State Medical Security Model, the Selective Medical Security Model and the Selective + Residual Medical Security Model. This approach provides useful policy implications for the health care reform currently taking place in China. In addition, this analysis contributes to theories in the comparative health policy literature.     

Explaining Different Paths in Social Health Insurance Countries – Health System Change and Cross‐border Lesson‐drawing between Germany,Austria and the Netherlands

The issues of ‘policy diffusion’ or ‘policy transfer’ and ‘mutual learning’ have become important topics in comparative research on social policy and health systems. In current debates on explaining reform in ‘Bismarckian’ social (health) insurance systems, however, these issues have been neglected. In particular, the role of ‘negative lesson‐drawing’ in the sense of avoiding mistakes of others has not often been considered. This article compares health system change in Germany, Austria and the Netherlands, three countries with health systems of the social insurance type. In contrast to the existing literature, our analysis stresses that these countries have taken different reform paths since the 1990s. By applying a most similar systems design, we analyze how far cross‐border lesson‐drawing has contributed to health system divergence in the three countries. The empirical basis of the analysis is semi‐structured qualitative expert interviews, a method appropriate for tracing processes of lesson‐drawing. We argue that in order to fully understand the diverging reform trajectories, we need to take into account how political decision‐makers refer to (negative) experiences of other countries. Generally, national driving forces for health system change were at the heart of many crucial reforms during the period studied. Nevertheless, we claim that it was the German bad practice role model that kept the reform paths of Austria and Germany apart in the Austrian health reform discussion between 2000 and 2005.     

‘Keeping families and children in mind’: an evaluation of a web‐based workforce resource

This study outlines pilot evaluation data of the web‐based training resource ‘Keeping Families and Children in Mind’, designed for clinicians who work with families where a parent has a mental illness. The resource was developed from scoping existing workforce packages and in consultation with consumers, carers, researchers and mental‐health clinicians. Preliminary evaluation data were collected from an urban and a rural site in Australia via focus group interviews and pre‐ and post‐training questionnaires to ascertain the experiences of those who participated in the training. Additionally, training facilitators were invited to maintain journals in order to identify planning and implementation issues when using the resource. Post‐training, participants emphasized the need to work collaboratively with others, as well as the importance of acknowledging and working with the family members of consumers, especially children. Also, participants reported positive changes in knowledge, skill and confidence when working with families affected by parental mental illness. Facilitators highlighted technology issues and the need to work interactively with participants when using the resource. Recommendations regarding policy and future research conclude this paper.     

‘Not a good person’: family stigma of mental illness from the perspectives of young siblings

The purpose of this paper is to critically examine family stigma as one form of the stigma of mental illness in child and youth mental health. Presented are the outcomes of a thematic content analysis of in‐depth, semi‐structured interviews conducted with seven (n = 7) young siblings, ages 13 to 21 years old, with a brother or sister identified as having a mental‐health issue. The focus of the interviews was on the ways the siblings experienced their other sibling's mental health and how those experiences shaped their sense of self and family. From the analysis, young siblings had predominately negative experiences, struggled with making sense of their brother or sister and the family as ‘flawed’ against the mental illness as ‘bad’ and experienced considerable family stress and overt family stigma. Current practice theories fail to consider the complexity of these factors and, in doing so, fail to adequately explain the nature and extent to which stigmatization occurs for immediate family members. The importance of peer support and understanding stigma in social work practice with children and their families is discussed.     

The future of inter‐country adoption: A paradigm shift for this century

Fronek P, Cuthbert D. The future of inter‐country adoption: a paradigm shift for this century The only existing international framework for inter‐country adoption (ICA) is a legal one. Current legal and welfare approaches have limitations in that ICA tends to be conceptualised in individualistic terms, while strategies that prevent ICA by strengthening communities and addressing structural inequalities in the first instance are neglected and divorced from ICA practice. A vision and an overarching framework based on a socioecological approach that informs other arenas, such as health promotion, are proposed. The article concludes that the development of collaborative, intersectoral approaches, the reorientation of public and private resources and international leadership from academics, legislators, policy makers, practitioners and communities are necessary for a paradigm shift for this century.     

Garbage‐can Policy‐making Meets Neo‐liberal Ideology: Twenty Five Years of Redundant Reform of the English National Health Service

The garbage‐can theory of decision‐making (Cohen et al. 1972), has been adapted into a perspective on policy‐making, with adaptations of the approach placing notable emphasis upon the health sector (Kingdon 2006; Paton 2006). This article creates an adapted ‘garbage‐can’ framework to help explain each stage of the reform of the English National Health Service (NHS) over the last 25 years. The emergence of the key idea and resultant policy at each stage of reform of the English NHS has been arational and indeed sometimes irrational. Policy has reflected advocacy by policy‐salesmen (Kingdon 2002), proffering ‘solutions’ to ill‐defined problems and answers to unasked questions, and politicians' short‐termist responses at each decision‐point. Yet the garbage‐can alone is not enough: if arationality rules in policy‐making day to day, this does not mean that there is not an overall ideological context, trend or bias in reform. The article also posits that ‘market reform’ has derived from the ideological hegemony of a naive anti‐statism (hostility to a misleadingly defined and often mythological ‘centralist state’) in public services and enthusiasm for market competition rather than any evidence‐based application of pro‐market ideas to health policy. A question arises: how are these two approaches (short‐term arationality and longer‐term ideological bias) combined in explanation of how policy over time is biased in a particular direction while seemingly arbitrary and directionless at each messy decision‐point. The article attempts to combine the insights of a garbage‐can approach with wider explanations of ideological hegemony.     

Making Sense of Inequalities: How Do Clinical Commissioning Groups in England Understand their New Role?

This research explored how newly forming clinical commissioning groups (CCGs) were beginning to think about their new ‘duty’ to tackle health inequalities (HIs), as outlined in UK health policy. The concept of ‘sensemaking’ (Weick 1995) was used to illustrate the influences on CCGs’ interpretations of the policy. Three CCGs in the North of England were recruited, and qualitative methods, including interviews, observations and document analysis, were used to collect data, over a period from January 2012 to December 2012. The tangibility of central policy objectives is important in providing clear guidance and direction to organizations trying to tackle large scale policy agendas such as HIs. At a local level, both individual and collective organizational histories and wider relationships were influential on the way CCGs understood the problem of HIs and how they decided to try to tackle the issue locally. The research highlights what influences local level relationships and what factors need to be considered when trying to interpret and implement national policy at a local level.     

Discourses about children's mental health and developmental disorders in North American women's magazines 1990–2012

This paper describes and analyses the portrayal of children's mental health and developmental issues (CMHI) in articles located in a random sample of a selection of available high‐circulating English language North American ‘women's magazines’ indexed in the Reader's Guide to Periodical Literature from 1990 to 2012. It is based upon a qualitative discourse analysis. CMHI are portrayed as materially, biologically real, prevalent and growing in incidence, and severity. They are also portrayed as located in the ‘non‐normal’, ‘non‐nice’, ‘disliked’ and ‘non‐successful’ individual child. Neither the facticity nor the biomedicalization of CMHI is questioned. The psy‐scientists and practitioners cited as experts for the ‘disorders’ offer contradictory and confusing information and advice. The possible theoretical and pragmatic explanations and consequences of this portrayal are discussed.     

Emotional kinship care and neutral non‐kinship care — the struggle between discourses

In this paper, social workers' ideas of kinship care and non‐kinship care as foster placement alternatives for vulnerable children are analysed and discussed. The study is based on group interviews with Swedish social workers, using a discourse analytic approach. The interviews took two vignettes of children who needed an immediate and long‐term placement because one of the parents had killed the other parent, as their point of departure. Domestic violence is a common social problem across countries, and controversies about placement alternatives become even more apparent when discussing lethal violence. The analysis revealed three main discourses: ‘emotional kinship care’, ‘neutral non‐kinship care’ and ‘a real family’. The emotional kinship care discourse also revealed two competing sub‐discourses: ‘emotions as glue that binds’ and ‘emotions as obscuring a child perspective’, displaying a struggle concerning the advantages and risks that social workers connected to kinship care. In this paper, the results and their implications for vulnerable children are discussed.     

Optimistic but Confused: Perceptions about the Mission and Core Values of Social Work in Vietnam by Vietnamese Policy‐makers,Social Work Faculty and Practitioners

In 2010, the Vietnamese government officially recognized social work as a profession. This study explores whether key stakeholders in the development of social work in Vietnam (i.e. policy‐makers, pioneering educators, and practitioners) had reached a shared understanding about the mission and core values of Vietnamese social work by the end of 2015. An exploratory survey was conducted with 65 participants representing key stakeholders of social work in Vietnam. Participants had a shared but rather generic, at times vague, and overly optimistic view of the mission of Vietnamese social work as a “helping profession” that would be able to solve every social problem and present in all areas. There was a strong, unanimous desire for Vietnamese social work to focus on human dignity, social justice, and individuals’ rights, mixed with the preservation of Vietnam's collective, community‐based culture under the central guiding role of the state.     

Risk and Public Protection: Responding to Involuntary and ‘Taboo’ Risk

Growing media, political and public concern with high‐risk offenders in the community has focused policy attention on the concept of ‘public protection’. A notion that the public has the right to be protected, particularly from ‘monstrous’ offenders such as predatory paedophiles, has infiltrated much recent legislation and penal policy. This article will explore the critical factors in the ‘public protection’ trend and the framing of risk and risky offenders that has ensued. In particular, attention will be given to the new surveillance and intervention mechanisms under the Multi‐Agency Public Protection Arrangements (MAPPA) and whether these arrangements manage risk or displace it. To what extent are they driven by the ‘precautionary principle’ and defensive responses to risks that are over‐inflated? To what extent does this result in ‘perverse incentives’ to over‐manage certain risks and to over‐concentrate on restrictive risk management techniques such as electronic tagging, satellite surveillance and curfews rather than treatment? Does the system represent effective risk management or a system for dealing with risk anxiety – both of the public(s) and of politicians?     

From ‘Rights to Action’: practitioners' perceptions of the needs of children experiencing domestic violence

Not only has research over the past decade documented the emotional and behavioural consequences for children who witness domestic violence, but a number of studies have used children as participants thus, giving them an opportunity to describe their experiences in their own words. In policy terms, there has been a growing emphasis on children's rights and the importance and understanding of children's perspectives on their own lives. Consequently, children can no longer be perceived as forgotten victims where domestic violence is concerned. This paper explores practitioners' awareness of the needs of children and young people living with, and fleeing from, domestic violence. The research, conducted in a rural area in Wales, reveals that although the views of practitioners reflect the concerns reported by young people in other studies, there can be barriers to meeting these needs. While policy prescribes engaging with children, at the institutional level, operational priorities and increasing administrative demands can actually reduce opportunities for working directly with children. These demands may hamper the development of multi‐agency practice.     

Intergenerational Relations between English Students,Graduates Living at Home,and their Parents

Debate about intergenerational relations has become more prominent since the financial crisis of 2007–09, focusing particularly on the difficulties faced by young adults trying to enter the labour and housing markets, whilst often bearing high levels of debt incurred as students. This article reviews the nature of the ‘intergenerational contract’ at both the micro level of the family, and at the macro level between individuals and the state. We then present qualitative, empirical data on the relationship between parents and: (1) their student children; and (2) their graduate children who have returned home. We focus primarily on the financial support provided by parents to the two groups. We explore why support is given, and the nature of similarities and differences in terms of what is given. We find that virtually all parents who were able to support their young adult children financially did so, but to different degrees and with different amounts of tension and anxiety. We suggest that the increased importance of the intergenerational contract at the micro level is likely to contribute to intra‐ rather than intergenerational inequalities.